Calming the Chaos


Drs. Blaise Aguirre and Gillian Galen

Drs. Blaise Aguirre and Gillian Galen. Photo by Jim Shaw.

New Book by Lexington Authors Applies Mindfulness Practices to Living with Borderline Personality Disorder

| By Laurie Atwater


Mindfulness for Borderline Personality Disorder: Relieve Your Suffering Using the Core Skill of Dialectical Behavior Therapy Blaise Aguirre MD (Author), Gillian Galen PsyD (Author) Available at, and

Mindfulness for Borderline Personality Disorder: Relieve Your Suffering Using the Core Skill of Dialectical Behavior Therapy.
The new book by Aguirre and Galen is available at, and




“I need to want to die less.”

This line appears in the introductory chapter of Lexington resident Dr. Blaise Aguirre’s new book Mindfulness for Borderline Personality Disorder: Relieve Your Suffering Using the Core Skill of Dialectical Behavior Therapy (New Harbinger Press) coauthored with his colleague and fellow Lexington resident Dr. Gillian Galen. Both Aguirre and Galen have spent their careers working with BPD patients at 3East, unit at McLean Hospital in Belmont devoted entirely to the treatment of females with borderline personality disorder (BPD).  Dr. Aguirre is the Medical Director at 3East and Galen is the Director of Training.

Sylvia, the woman quoted above is reaching out for help.

Working with patients in this kind of mental pain is the challenge at 3East. Currently women are more frequently diagnosed with BPD (75-90% of those diagnosed with BPD are women according to the Borderline Personality Research Center at New York Presbyterian Hospital). Research is being done to validate this working assumption and the situation may change in years to come, but for now, female teens are the faces of BPD.

Because many of the symptoms of borderline personality disorder can closely resemble what we perceive as ordinary adolescent behavior, BPD often goes undiagnosed until a traumatic event occurs. According to the Borderline Personality Research Center, “10%, or one in ten, people with BPD commit suicide. Thirty-three percent of youth who commit suicide have features, or traits, of BPD. This number is 400 times higher than the general population, and young women with BPD have a suicide rate of 800 times higher than the general population.”

Parents faced with moody, withdrawn, sad or angry adolescents often assume that their child is just suffering the normal ravages of teen years—and most are. However, individuals with BPD are so emotionally charged that their feelings erupt quickly and more intensely than an average teen and they take much longer to calm down. This emotional instability is the calling card of the disorder.

They also experience self-loathing, feelings of worthlessness and hopelessness about the future combined with an intense fear of abandonment. They are very often suicidal and many BPD sufferers make several suicide attempts. About one in ten are successful, and this is why it is critical to identify this disorder early and get effective treatment.

Many teens are great at disguising their suffering and looking quite “normal” on the surface for long periods of time. In fact BPD patients can be very high functioning, but they almost inevitably erupt in episodes that are so out of control they are really scary—especially to parents. BPD kids’ lives are in a perpetual state of drama and chaos.

Galen says that patients come to McLean when they are in a pretty fragile state. “They are sick a lot, chronically tired, sleeping is poor and they are often overmedicated. These kids are living on a constant roller coaster of emotions. A typical adolescent might come home from school angry and frustrated and there could be door slamming and screaming, but they will go to their room and regulate themselves and come down to dinner. They can have momentary mood dysregulation but still have a normal life—go to school, do their homework.”

“But BPD kids are so mood dependent that they can’t finish things. They drop out of activities. They don’t make it through sports season. They can’t ever find something that they like.”

BPD is obviously very disruptive to the family unit. “People start walking on eggshells around these kids because they are so unpredictable,” Galen says. “What happens is the child threatens an extreme act like suicide as a way of getting what she wants and if the child has that history (of attempting suicide), the parents become frightened and refuse to set limits. Out of fear for their child they end up reinforcing the bad behavior.” This dangerous dance can have dire consequences.

Behaviors like cutting (self-injury that involves puncturing or cutting the skin to release tension) burning, excessive drinking, irresponsible sex and reckless driving may provide behavioral clues for concerned parents who are ill equipped to handle these kids who have huge emotional swings and can be chronically acting-out.

 According to DSM-IV criteria (DSM-IV is considered the diagnostic “bible” for psychiatric disorders), signs and symptoms include:

  • Make frantic efforts to avoid real or imagined abandonment.
  • Have a pattern of difficult relationships caused by alternating between extremes of intense admiration and hatred of others.
  • Have an unstable self-image or be unsure of his or her own identity.
  • Act impulsively in ways that are self-damaging, such as extravagant spending, frequent and unprotected sex with many partners, substance abuse, binge eating, or reckless driving.
  • Have recurring suicidal thoughts, make repeated suicide attempts, or cause self-injury through mutilation, such as cutting or burning himself or herself.
  • Have frequent emotional overreactions or intense mood swings, including feeling depressed, irritable, or anxious. These mood swings usually only last a few hours at a time. In rare cases, they may last a day or two.
  • Have long-term feelings of emptiness.
  • Have inappropriate, fierce anger or problems controlling anger. The person may often display temper tantrums or get into physical fights.
  • Have temporary episodes of feeling suspicious of others without reason (paranoia) or losing a sense of reality.


A great YouTube video about BPD , Back From the Edge offers guidance on treating Borderline Personality Disorder. The video was created by the Borderline Personality Disorder Resource Center at New York-Presbyterian.


In his 13 years as the Medical Director at 3East, Aguirre has remained passionately hopeful about the prognosis for those diagnosed with BPD, though he admits they can be frustrating to diagnose and treat. Patients often have symptoms that overlap with other illnesses and many teens may have received several different diagnoses that never quite fit before making it to 3East. Dr. Aguirre stresses that it is extremely important to get the right diagnosis because BPD sufferers do not respond to the same drugs or treatment modalities as more commonly diagnosed conditions like conduct disorders, depression or bi-polar disorder. It’s also important to catch this disorder early. Although there is some controversy about the diagnosis of BPD before age 18, temperamental tendencies can be identified early, and Dr. Aguirre feels that early intervention is critical. Research shows that dialectical behavior therapy (DBT) reduces the incidence of suicide attempts and keeps teens in therapy for longer periods of time. Untreated, BPD symptoms can persist into adulthood, but with treatment the outlook for a successful life is greatly improved. “Kids stick with it,” Aguirre says, “because they want out of their misery—they are in so much pain.”


Marsha Linehan of the University of Washington is one of the leading experts in BPD. Dr. Linehan has developed a biosocial theory of  BPD  over many years of dealing with highly suicidal, treatment-resistant patients. On the biological side of the equation she theorizes that BPD patients have a lower neurological threshold for emotional stimulation.

New research published in the journal Biological Psychiatry in this past January shows that the emotional priming for BPD may well be biological as Linehan theorizes. A recent review of imaging studies by neuropsychologist Dr. Anthony Ruocco at the University of Toronto (Ruocco is a clinical neuropsychologist who specializes in the use of neuropsychological and brain imaging techniques to understand the brain. His primary area of interest is in identifying biological liability markers of borderline personality disorder) recently observed heightened activity in brain circuits involved in the experience of negative emotions, and reduced activity of brain circuits that are normally recruited to regulate emotion.

Aguirre and Galen have an entire section of their book devoted to brain imaging, genetics and brain chemicals. They present the science showing that BPD sufferers have an overactive amygdala (fight or flight central) and an underactive prefrontal cortex (the seat of reason and control). The interaction between the two regions of the brain is out of balance in BPD sufferers as brain scan studies like the one cited above have shown.

On the social side of BPD, Dr. Linehan has identified that BPD patients suffer the effects of an invalidating environment. This is an environment that is experienced as hostile by and to the BPD patient—where their emotions are seen as unacceptable and are often dismissed or punished. This can be very difficult for loved ones to comprehend. Dr. Aguirre explains that many “invalidating” remarks and behaviors are often used  innocently by loved ones to “console” or to “help” someone who is in psychological distress. Things as common as telling someone ‘cheer up, it’s not that bad’,  ‘you’ll be fine’ or  ‘just get over it,’ can invalidate a BPD sufferer’s feelings. When the BPD sufferer experiences a negative and stressful situation like a breakup with a boyfriend or a fight with a friend and is met by invalidating comments, a cycle of self loathing, anger and acting-out may begin. These episodes often end in self-harming behaviors that are, to the BPD sufferer, a form of self-calming.

Based on her clinical experience, Dr. Linehan pioneered a practice known as DBT (dialectical behavior therapy), the therapy that is now considered the gold standard treatment for BPD. This  program used with great success with teens at McLean.


DBT balances empathy and acceptance with an unwavering focus on changing problem behavior. Through this balance, DBT aims to help change the behavioral, emotional, and thinking patterns associated with problems in their lives, while promoting the development of, and reliance on, an inner wisdom—something Linehan calls the “wise mind.”

“What makes DBT so successful,” Aguirre explains, “is that it is extremely accepting that a person has the limitations that they have. It accepts them at face value without making any interpretations or judgments.” This accepting and validating  therapeutic relationship nourishes the patient’s ability to see that change is necessary to end their pain and suffering.

But it is not only the therapist that must practice non-judgmental acceptance. The patient must also be able to accept themselves and their situation. Linehan calls it Radical Acceptance which means being nonjudgmental of the self and accepting life as it is. Dr. Linehan found that without this fundamental acceptance it is almost impossible for patients to progress in therapy.  And many drop out because of this.

“This is a process that you have to accept over and over again,” Gillian Galen says. “But,” she adds, “pain plus non-acceptance equals more suffering. We have skills for dealing with difficult feelings, none for non-acceptance.”

The “dialectic” in DBT is this notion of holding the opposing ideas of acceptance and change in balance. This dialectical approach acknowledges the yin and yang of feelings, situations and relationships and get away from black and white thinking (good/bad, right/wrong). Through practice it helps patients synthesize opposing thoughts and feelings into their “wise mind”—a balanced place between acceptance and change.

When patients come to treatment, they often have a hard time with the concept of acceptance. They can’t accept themselves, the diagnosis, the love and caring of their friends and family or the reality of circumstances that they find difficult. They will argue their position and feel extremely misunderstood when others don’t agree with them.  But once the threshold has been crossed the change can begin, and it is typically very effective.

The formal aspects of DBT training involve individual meetings with therapists, classroom style training in the fundamental skills of DBT–mindfulness, interpersonal effectiveness, distress tolerance and emotional regulation—and group training sessions in which patients learn to incorporate the skills into life situations. In DBT therapy sessions life-threatening behaviors are always addressed first and then work continues on specific situations and feelings that have caused pain. It is typically a one year process with follow-up.

“The theory that we hold is that BPD is, in part, a skills deficit,” Galen explains. “These are people, who along the way in their development, didn’t learn these skills so we teach them the skills, how to use them, when to use them and then we give them coaching in the moment.” DBT takes time and dedication to unwind these individual and family patterns.

“The brain does not distinguish in any way, shape or form between adaptive or maladaptive behaviors—good, bad or indifferent,” says Aguirre. “What we know is reinforcement behavior—the more you repeat something the better you get at it. So, if you keep repeating the same maladaptive behaviors you get really good at it.”  The same holds for adaptive behaviors. DBT is a process of identifying problematic thinking and behavior and swapping it out for the newly acquired adaptive behaviors and then reinforcing and repeating the process through role play and therapy until it forms new muscle memory for the patient—a DBT toolkit at the ready when needed. “In large part we are teaching patients to pay attention to those things that just aren’t working for them,” Aguirre says, “As therapists we’re the sympathizers, the tool-givers and the cheerleaders.”

DBT also requires the commitment of the parents. “We ask the parents to participate in a skills group because we have to change these transactional patterns that have developed over time,” Galen says. Aguirre says, “In my psychiatric career, the vast majority of parents who have these kids are the kindest, most well-meaning parents who just don’t understand how difficult their kid’s struggle is, and they don’t always have any experience with these types of feelings.” DBT can work wonders in interrupting this painful cycle and creating new habits for both parents and their suffering children.

Learning to identify the physiology, thoughts and situations that trigger emotional reactivity is the biggest challenge for patients. They have the tools, but when to use them? This is where mindfulness comes in. Mindfulness is the core skill of DBT.


Sarah was a patient at the 3East Residential Program at McLean. She generously shared her story with us by phone from college where she is continuing her education. Sarah uses the skills of mindfulness and DBT every day. 

“I started getting depressed around my junior year in high school. I’ve always been a perfectionist and a really hard worker in school. I started feeling really overwhelmed with my work. I wasn’t sleeping enough and all I cared about was school. I just felt out of control in life and I didn’t know what was going to happen the next day. That continued into my senior year when I had my first suicide attempt and my first inpatient hospitalization.

During my junior year I started cutting but I never really did it for very long. I went to public schools my whole life, but in an area where everything is so competitive. Everyone was so smart and so good at sports and I just felt—even when I was getting good grades—someone else was better than me. That made it a lot worse. You just lose sight of reality. Everyone in my area is this certain way and it’s expected that you go to college and maybe even get a graduate degree.

After high school I realized that there’s a whole lot more to this world.
In the fall of 2009 I went off to Emory University and I lasted about six weeks there before I had a major breakdown. Before my first exam I had a panic attack. The school sent me home and said I wasn’t taking care of my health. I was really devastated when they told me I had to leave school—I thought it was ridiculous, but when I got home I realized it was definitely the right decision because I needed more help so I went into the day program at McLean.

After my next suicide attempt I went to 3East—the residential unit at McLean. I absolutely loved the program and I would definitely say that it saved my life. Living on the unit with everyone about my age going through the same things—it was like a family.Eighty-five percent of the time I am perfectly fine and then I have a huge breakdown and I get suicidal.

But it was hard at first to go to treatment. My whole life growing up, I never thought it was okay to ask for help. That was the first hurdle. Once you’re able to accept it it’s a lot easier to make progress.

My parents never dealt with anything like this before. I’m the only one in u family to have mental illness and my parents had no idea. They just thought I was being an angst-y teen. I refused to talk with them. They would ask me how school was and I would snap at them. I tried to distance myself from them. That’s when they knew something was up. My friends weren’t really coming around and I was spending all my time in my room. I know they definitely had to read into the signs—it wasn’t obvious to them. Now I realize that my parents have always been pretty worried about me.

I struggle with anxiety. Most of the time I don’t even know what I’m anxious about. But since I’ve learned DBT I’ve started to pay attention to it. I’ve learned to pay attention to all of the feelings and sensations and then I think, ‘is there a cause for this? Is there really anything to worry about? It’s been really helpful. There are four modules in DBT and I’ve probably been through them all many times. In those moments when I’m really distressed, using a skill can really help, but it’s hard. I have to find the skills that really work for me.
I really loved doing the yoga.

I’ve started going to yoga classes on my own and it’s amazing how it can calm you down and put you in a different mindset. It stops you from thinking about the future.”



Mindfulness practice has been shown to mitigate the underlying problem of BPD by activating and strengthening the prefrontal cortex and reducing the body’s stress mechanisms.

The concept of mindfulness has exploded throughout American culture.  A mainstay of Eastern religions, this practice has been inching its way into the Western mainstream for some time. In Lexington, our own Jon Kabat-Zinn has been on the forefront of exploring Mindfulness-Based Stress Reduction (MBSR) which he launched at the University of Massachusetts Medical School in 1979. Since that time, thousands of studies by Zinn and others have documented the physical and mental health benefits of mindfulness.  Mindfulness is being used to combat stress in the classroom, in business and in just about any setting where attention is being hijacked by modern life. With roots in the Buddhist tradition, mindfulness meditation involves paying attention to thoughts and feelings in the present moment and accepting and letting go of those feelings and emotions non-judgmentally. A mindfulness practice can give the participant more control over their thoughts and feelings and has been proven empirically to result in more activation in the pre-frontal cortex.

“If you look at mindfulness-based stress reduction it has shown lots and lots of efficacy in many medical conditions,” Aguirre says.  “Though the research on mindfulness specifically for BPD is scant, through clinical observation, we see the kids who use mindfulness recover much more quickly. It is imperative that we as clinicians pay attention to things that work.” Teaching patients to slow down their breathing and check in with their bodies can help them identify the biological stress signals that the body sends before they react emotionally. Once they realize that their pulse is racing, their palms are sweating, their breathing is shallow or any of the myriad physical symptoms they may suffer, they can reach for a DBT skill that might help them to cope.


About 7 years ago Dr. Aguirre was attending a conference in Washington D.C. and happened to be seated next to BPD expert Dr. Marsha Linehan.  Aguirre had been at McLean practicing using the DBT program for several years with adolescents and he was becoming more and more interested in the mindfulness component of the program.

“I heard that Dr.Linehan was doing training in Tucson and I asked her to get me in,” he says with a short laugh. What Aguirre learned upon arriving in Arizona was that the “training” had nothing to do with DBT. “It was a Catholic monastery and I had to be sitting there staring at a wall in silent mindfulness for sixteen hours a day,” he laughs.

Admittedly he panicked, called his wife and begged for her to make up an excuse to get him out of there. “She hung up on me,” he says ruefully.

“So there I was stuck in the monastery with Marsha Linehan and it changed my life,” Aguirre says. “I finally woke up to the way my mind works.”

Aguirre’s co-author Gillian Galen came to mindfulness through yoga. A dancer and an athlete, Galen relocated to West Hartford, Connecticut for her graduate work and found herself looking for some dance or sport that she could fit in with her studies. She ended up in a yoga studio and fell in love with the practice. “I got really hooked on yoga,” she explains “and I started to notice myself changing off the mat and I was fascinated by it.”  Galen noticed that she could come to yoga after hours of studying and clinical work and within fifteen minutes my mind would go from spinning to a sense of quiet and soon I became interested in the science behind it.”

Galen ended up writing her doctoral dissertation on the effects of yoga on mental health. “People began noticing how level I was. I was much less judgmental. I was paying attention and I was essentially ahead of my experience and all of this was happening as I was developing as a psychologist.”  Galen had worked for a time at McLean before doing her graduate work so she had some exposure to DBT. “Once I added yoga it all came together.”

The last time I saw Aguirre and Galen they had just returned from a mindfulness retreat. So they are both “all in” on mindfulness and what it can do to enhance anyone’s life.  But its application to DBT is essential for success.


Skill-building is the backbone of the DBT program or as Aguirre says: “Skills not pills.”

Being mindful, learning to sit with difficult emotions without resorting to old behaviors, learning to reframe internal thoughts and calm overactive emotions—this is DBT and the work that goes on at 3East.  The program has shown so much success that Aguirre and Galen wanted to share it with those who are unable to participate in a hospital-based program. Their new book lays out a path to end the suffering of BPD through DBT focused mindfulness training.

“We had a great time writing the book because we love mindfulness and we love thinking about it,” Galen says. “It’s changed both of our lives completely and we loved trying to figure out how to bring it to people in a very easy, non new-age-y, non-judgmental way.”

Writing this book was a labor of love, but it required lots of hard work. Galen and Aguirre staged marathon writing days on the weekends, joining up with their respective spouses for dinner and then starting it over again the next day. “We have crazy work schedules so we just had the weekends, and we did this for multiple weekends a month,” Galen explains. “Our families were very understanding!”

What they have produced is a highly readable book that incorporates case studies, accessible explanations of the science and symptoms of BPD, and a plethora of mindfulness exercises. The book immediately engages by speaking directly to the reader in a down-to-earth and compassionate voice.

The authors very clearly discuss BPD in all of its dimensions, the concept of mindfulness and its application to BPD, and the neuroscience underpinning both. The balance of the book is devoted to explaining a series of known BPD behaviors like emotional instability and anger, unstable relationships, fear of abandonment, impulsivity, self-injury (and many others), and teaching mindfulness exercises that can be helpful in interrupting old patterns.

“Whether you have borderline personality disorder or not, these skills help anyone,” Galen says. “We’ve had parents tell us that they use these skills at work now.”

Learning to calm a frenzied mind and quiet the emotions through mindfulness helps patients to do the necessary work of building their DBT toolbox and to ultimately learn to see themselves, and the world, in a way that’s less judgmental, gentler and more hopeful.


McLean’s DBT Programs

The program specializes in intensive dialectical behavior therapy (DBT). 3East now offers four levels of individualized care; enabling teenagers and young adults to fully benefit from ongoing, consistent treatment and support at varying levels of care:
-3East Residential Intensive. A program for teens and young women, ages 13 through 20.
-3East Residential Step-down. A program for “graduates” of the “3East Residential Intensive” treatment, ages 13 through 20.
-3East Day Program. A mixed-gender, non-residential day program, for individuals, ages 13 through 20, who live in the surrounding area or have completed the 3East Residential Intensive program and reside on the 3East Step-down unit.
3East Transitional Care. A program for women 18 through 25 who have already received intensive dialectical behavior therapy (DBT) treatment and would benefit from extended care before returning to live independently in the community.


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